Failure to Provide Timely Follow-Up, Skin Care, and Laboratory Monitoring
Penalty
Summary
The facility failed to ensure residents received appropriate follow-up care and treatment as ordered and required. One resident with a diabetic foot ulcer and a bone infection was referred for an infectious disease consult, but there was no documentation that the resident attended the scheduled appointment, nor were there any records of follow-up or recommendations from the consult. Staff confirmed the resident did not attend the appointment, despite the importance of evaluating for underlying infection. Two other residents did not receive proper skin assessments, monitoring, or treatment. One resident with a history of fractures, pressure ulcers, and functional limitations had visible signs of ingrown toenails and discharge, but had not seen a podiatrist since admission. Staff confirmed that these skin issues should have been identified and reported during daily treatments. Another resident with heart disease and lymphedema had physician orders for daily edema assessment and use of compression stockings, but was repeatedly observed without stockings and with significant swelling. Staff documentation of edema levels did not match the resident's actual condition during observations. Additionally, a resident with a diagnosis of vitamin D deficiency was prescribed a high-dose vitamin D supplement without any evidence that a vitamin D level was obtained prior to starting the medication. Staff interviews confirmed that a vitamin D level should have been checked before initiating supplementation, but this was not done. These failures resulted in missed or delayed care and incomplete monitoring for multiple residents.